Laserfiche WebLink
INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name; 8 /►1 /y OAA' LtM0 t4 I <br />neitity Address: /56L AL Cl nortA <br />-- rS4ackiOn Ps 9�. •/ <br />Telephone; <br />Person Filing / <br />R / n <br />Re ort ort d 11 <br />�( 4tt a.ee a <br />�i hereby certify Under penalty of perjury that all inventory variations for <br />the above s.encioned facility were vichin the allowable limits for this <br />quarter. (No in Column 13 of the lovencory Reconciliation Sheet) <br />laventory variations exceeded the allowable limits for this quarter. L <br />hereby certify under penalty of perjury that the source for the variation <br />vas not due to as unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) <br />List date. tank /a and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank I Amount <br />Addicioaal dates/amounts shall be continued oa a separate sheet of <br />Paper and attached. <br />if the source of the variation which exceeded allowable limits was due to <br />a leak the incident shall be reported to S.J .L.H.D. Environmental licalth <br />within 24 hours and an unauthorized release report submitted. <br />The quarterly summary re port shall be submitted within 15 days of the end of each <br />Quarter. <br />Quartir I - January --> March <br />Q•Iart.-r 2 - A ril --) Juu.- <br />arter ) - July -_) Septcmher Jam <br />Q�urter 4 - c o cr -- III ICU <br />Send to: SAN JOAQUIN I,OCAI. IIEAI,TIi DIS'lltICT <br />1601 li. Haze l(on, V.0. Box 1`009 <br />SLockton. CA 95201 466-61b1 <br />1' h(l 10/N6 <br />